Fibroids and Still Having Pain After Endometriosis Was Removed: Why It Happens and What Helps

September 13, 2025

Fibroids and Still Having Pain After Endometriosis Was Removed: Why It Happens and What Helps

If you had endometriosis surgically treated but pelvic pain continues, you are not alone. Endometriosis and uterine fibroids often coexist, and pain can have more than one source. Understanding why symptoms persist helps you and your care team target what’s really driving your pain and choose treatments that work.

Why pain can persist after endometriosis surgery

Even when endometriosis lesions are removed, pain pathways can remain active, and other gynecologic or pelvic conditions may still be present:

Coexisting fibroids: Fibroids are very common benign uterine tumors that can cause cramping, pressure, back pain, and pain during periods—independent of endometriosis.
Adenomyosis: Tissue similar to endometrium grows into the muscular wall of the uterus, causing heavy, painful periods and a “boggy,” tender uterus. It frequently co-occurs with fibroids and endometriosis.
Residual or recurrent endometriosis: Microscopic disease can be missed and lesions can recur over time, especially with ongoing ovarian hormone production.
Pelvic floor muscle dysfunction: Muscles become tight and tender, contributing to deep pelvic or vaginal pain, pain with sex, or pain after bowel movements.
Central sensitization: The nervous system becomes more sensitive after long-standing pain, amplifying pain signals even after a trigger is removed.
Adhesions or nerve irritation after surgery: Scar tissue or nerve sensitization can fuel ongoing pain for some people.
Other pelvic conditions: Irritable bowel syndrome (IBS), interstitial cystitis/painful bladder syndrome (IC/BPS), ovarian cysts, and pelvic congestion can mimic or compound gynecologic pain.

How fibroids can drive pain after endometriosis surgery

Fibroids don’t always cause symptoms, but when they do, pain is common. Mechanisms include:

Uterine cramping and heavy bleeding: Submucosal and intramural fibroids can intensify period cramps and bleeding.
Pressure and bulk symptoms: Larger fibroids can cause pelvic pressure, low back pain, urinary frequency, constipation, or pain with sex by pressing on nearby organs.
Degeneration: When a fibroid outgrows its blood supply, it can cause acute localized pain (sometimes with fever or tenderness).
Torsion of a pedunculated fibroid: Rare, but can trigger sudden severe pain requiring urgent evaluation.

Endometriosis surgery typically targets endometriotic lesions, not fibroids. If fibroids were not treated—or new fibroids developed—these may explain ongoing symptoms.

Other common culprits to consider

Adenomyosis: Often presents with heavy, painful periods and an enlarged, tender uterus. MRI can improve detection.
Pelvic floor dysfunction: Frequently overlooked and highly treatable with pelvic floor physical therapy.
Bladder or bowel conditions: IC/BPS and IBS are common in people with chronic pelvic pain and can flare with stress or hormonal changes.

How clinicians figure it out

A thorough, stepwise evaluation helps pinpoint pain generators:

History and pain mapping: When the pain occurs (cycle-related or constant), location, triggers (sex, bowel movements, urination), and response to past treatments.
Pelvic exam: To assess uterine size/position, tenderness, nodularity, and pelvic floor muscle tone.
Imaging: Transvaginal ultrasound is first-line for fibroids; MRI can refine surgical planning, detect adenomyosis, and evaluate deep disease.
Labs when indicated: Pregnancy test, CBC for anemia (heavy bleeding), urine testing for bladder involvement.
Targeted referrals: Pelvic floor physical therapy; urology for IC/BPS; gastroenterology for IBS or constipation.

What helps now: A layered plan for relief

The best results often come from combining fibroid-directed care with pain-focused therapies.

1) Treat the fibroids (and adenomyosis if present)

Medical options (nonsurgical):

NSAIDs: Reduce menstrual cramping and pain.
Hormonal suppression: Continuous combined oral contraceptives or progestin-only methods (including the levonorgestrel intrauterine device) can lighten bleeding and pain for many.
Tranexamic acid: Non-hormonal option that reduces heavy menstrual bleeding.
GnRH pathway medicines: Short-term use of GnRH agonists (e.g., leuprolide) or oral GnRH antagonists with add-back therapy can shrink fibroids and reduce bleeding/pain. FDA-approved options include relugolix-estradiol-norethindrone (Myfembree) for heavy menstrual bleeding from fibroids and for moderate to severe endometriosis pain, and elagolix-estradiol-norethindrone (Oriahnn) for fibroid-related heavy bleeding. These are typically time-limited due to bone density effects and other side effects; add-back hormones help mitigate risks.

Uterus-sparing procedures:

Myomectomy: Removes fibroids while preserving the uterus; preferred for those seeking future fertility.
Uterine artery embolization (UAE): Shrinks fibroids by blocking their blood supply. Effective for bleeding and bulk symptoms; discuss fertility goals before choosing.
Radiofrequency ablation (laparoscopic or transcervical): Uses targeted energy to shrink fibroids with typically quicker recovery.
MRI-guided focused ultrasound: Noninvasive thermal ablation for select candidates.

Definitive surgery:

Hysterectomy: A definitive option when childbearing is complete and other treatments have not controlled symptoms, especially with concurrent adenomyosis.

2) Calm the pain system

Pelvic floor physical therapy: First-line for muscle-related pelvic pain, dyspareunia, and post-surgical guarding.
Neuromodulating medications: Serotonin-norepinephrine reuptake inhibitors, tricyclic antidepressants, and gabapentinoids can help neuropathic and centralized pain in select patients.
Trigger point injections or nerve blocks: Considered when focal myofascial or nerve pain is identified.
Pain psychology and lifestyle: Cognitive-behavioral therapy, paced activity, sleep optimization, heat, gentle exercise, and TENS can reduce flares.

3) Prevent endometriosis recurrence

After excision, many patients benefit from ongoing hormonal suppression to lower recurrence risk and dampen cycle-related pain. Options include continuous combined hormonal contraception, progestins (oral, IUD, injection), and GnRH antagonists with add-back under close supervision.

When to seek care—urgently

Sudden, severe pelvic pain (especially with nausea/vomiting)—could signal degeneration or torsion of a fibroid or an ovarian issue.
Heavy bleeding soaking through pads/tampons hourly, dizziness, or fainting.
Fever, foul discharge, or severe tenderness after a procedure.
Possible pregnancy or positive pregnancy test with pain.

How to advocate for yourself

Track symptoms with a pain and bleeding diary to show patterns.
Ask whether your imaging fully evaluated fibroids and adenomyosis (and if MRI might help).
Request a pelvic floor assessment if intercourse, tampon use, or exams are painful.
Discuss both fertility desires and recovery goals when considering procedures.

Bottom line

Persistent pain after endometriosis surgery is common—and treatable. Fibroids, adenomyosis, pelvic floor dysfunction, lingering or recurrent endometriosis, and bladder or bowel conditions may all contribute. A tailored plan that addresses fibroids directly and calms the pain system often brings the best relief. Partner with a gynecologist experienced in endometriosis and fibroid care, and don’t hesitate to involve pelvic floor therapists, pain specialists, and GI or urology colleagues when needed.

Sources and further reading

NIH/NICHD: Endometriosis. https://www.nichd.nih.gov/health/topics/endometriosis
U.S. Office on Women’s Health (HHS): Uterine fibroids. https://www.womenshealth.gov/a-z-topics/uterine-fibroids
ACOG Patient FAQ: Uterine Fibroids. https://www.acog.org/womens-health/faqs/uterine-fibroids
FDA: Myfembree (relugolix/estradiol/norethindrone) prescribing and indication updates. https://www.fda.gov/drugs
FDA: Oriahnn (elagolix/estradiol/norethindrone) for fibroid-related heavy menstrual bleeding. https://www.fda.gov/news-events/press-announcements/fda-approves-treatment-women-heavy-menstrual-bleeding-associated-fibroids-0
NIDDK: Interstitial Cystitis/Bladder Pain Syndrome. https://www.niddk.nih.gov/health-information/urologic-diseases/interstitial-cystitis-painful-bladder-syndrome
U.S. Office on Women’s Health: Adenomyosis. https://www.womenshealth.gov/a-z-topics/adenomyosis
ACOG Patient FAQ: Chronic Pelvic Pain. https://www.acog.org/womens-health/faqs/chronic-pelvic-pain